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General NPI Number Information
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NPI Number | 1528074077
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Entity Type | Individual
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Provider Name | JOHN CLARK MAYBERRY MD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 10/03/2023
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Provider Practice Location Address
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Address Line | 1906 FAIRVIEW AVE STE 130
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City | CALDWELL
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State | ID
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Zip | 83605-5433
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Country | US
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Telephone | 208-453-4260
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Fax | 844-213-3678
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Provider Business Mailing Address
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Address Line | PO BOX 1074
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City | CALDWELL
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State | ID
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Zip | 83606-1074
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Country | US
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Telephone | 208-453-4260
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Fax | 844-213-3678
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number | M-12108
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | M-12108
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License Number State | ID
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